Ridge Expansion Osteotomy , Osteotome Technique
The placement of implants in edentulous areas is often compromised by a thin alveolar crest. This reduction in the width of the edentulous ridge may make the final prosthetic results less than ideal. To correct this, various techniques have been described for widening, including revascularised block bone grafts, alveolar distraction osteogenesis, guided bone regeneration, and splitting to expand the ridge.
However, these methods have limitations, including the need to harvest bone from intraoral or extr-oral sites along with increasing the time frame for the entire treatment during which the bone conditioning takes place which can be many months in a lot of cases before the implants can be placed.
With the Osteotome Technique displayed in these video the implant osteotomy can be prepared without any ostectomy / bone removal and the implants can be inserted in the prepared sites . However to use this technique there needs to be a minimum 3mm of pre-existing bone width at the desired implant placement site .
The post is a 2 part surgery video performed at Praxisclinic by Dr.Varun Malhotra , which demonstrates the use of this technique for osteotomy and the placement of the implant ( active implant ) in the prepared site.
Ridge Expansion Osteotomy (Osteotome Technique)& Immediate Implant (Alpha Biotec) placement:Part 1
Ridge Expansion Osteotomy (Osteotome Technique)& Immediate Implant (Alpha Biotec) placement:Part 2
Piezosurgery and dental surgical applications
Piezosurgery utilizes piezoelectric vibrations for cutting bone tissue. By adjusting the ultra sonic frequency of the device, it is possible to cut hard tissue without damaging the soft tissue.
Piezosurgery units are available with various tips which enable them to be used in a variety of bone surgery situations. Also these units enable precise cutting which helps conserve bone tissue.
This video demonstrates the the use of a piezosurgery device ( Piezotome , by Acteon/Satelec ) in conjunction with their Extraction Tips / Extraction kit , to extract an ankylosed ( fused to bone) root piece from the lower jaw , which is to be rehabilitated with a dental implant .
The use of piezotome yields the root piece easily and preserves the bone around it , that will aid in the implant placement .
An Overview of Replacing Missing Teeth with Dental Implants
Dental Implants
A dental implant is a titanium device intended to replace and rehabilitate a single or multiple or the entire set of missing teeth in the jaw bones.
The dental implants have evolved to a great extent over the past many years and the extensive research and development in the implant designs and coatings have made the implants as an established and a predictable means of replacing the lost or failing natural teeth .
There are various companies offering implants with extensive research and backing behind their implant designs and coatings e.g. Nobel Biocare ™
The dental implant designs have evolved to the extent that they can be used to replace teeth extracted/ lost since a long time ( delayed placement ) or they can be used to replace teeth immediately at the time of extraction (immediate placement ***–all teeth are not suitable for immediate replacement with implants and can be done under certain situations only )
Parts of a dental implant :
The dental implant broadly speaking has 2 identifiable parts :
-
Implant body : the portion of the implant that is placed in the bone and integrates with it .
-
Implant abutment : the portion of the implant that extends into the mouth , and on the top of which the tooth crown or other attachments components may be placed.
****The implants may be available as 2 separate components ( 2 piece implants ) or as one single component ( one piece implants ) and these different types of implants may be placed by the implantologist as per the demands of the clinical situation .
Replacement of teeth with implants is a surgical procedure that usually requires pre-planning with x-rays and or ct scans and an overall medical evaluation prior to implant placement to ensure long term success and predictability of the implant based rehabilitation.
The dental implant based rehabilitation broadly fall under the following categories:
- Single Tooth Implant
- Multiple teeth Implants
- Full Mouth/ Arch /Jaw rehabilitation with implants.
- Dental implants to support dentures / Implant supported dentures.
1.Single tooth Implants:
One implant or two implants may be used to replace s single missing tooth.
The implant may be placed long after the tooth is extracted or may be placed immediately after extraction.
The cap / tooth/ crown may be placed after a few months of the implant placement surgery allowing it to integrate with the bone. ( osseointegration )
With the advancements of the implant designs newer implants allow placement of the crown over the implants immediately after surgery, provided that the conditions are suitable to do so.
Since placement of implants requires adequate amount of bone in the jaw site chosen for implant placement, in cases where the bone is not adequate for implant placement, bone conditioning (bone augmentation) may be required by a means of separate surgery or at the time of placement of the implant itself.
2.Multiple teeth Implants
In situation where multiple adjacent teeth are missing their replacement with implants can be done by :
-
One implant for each missing tooth as single tooth implants. or ,
- A bridge may be placed over a few implants like it is done in natural teeth: in this scenario less number of implants can be an option to replace multiple teeth. The number of implants to be placed is decided by the implantologist after evaluation, as mentioned earlier.
3.Dental implants to support dentures / Implant supported dentures.
Patients who already have full mouth dentures / full jaw dentures and facing the problems with denture instability and movement of the denture while talking and eating , can take advantage of the dental implant procedures to enhance the support and stability of the existing dentures .
In these situations the dental implants placed in the bone with special components placed over the implants and their counterpart components in the dentures , provide a means of anchoring the denture to the jaw bone , in turn enhancingthe support and stability of the denture , and making the existing denture more comfortable.
4.Full Mouth/ Arch /Jaw rehabilitation with implants.
Implants in todays time have become an accepted and a predictable modality to replace all the missing teeth in one or both the jaws as per the clinical situation.
Different techniques may be used to replace depending on the number of implants decided to replace the teeth as per the availability of bone like :
-
All-on-4 ™ ( 4 implants for replacing all the teeth )
-
All- on 6 ( implants for replacing all the teeth )
-
8-10 implants for replacing all the teeth .
The set of teeth placed on the implants may be cemented n the implants or placed with screws, which offers the ease of removing the whole set of teeth from the implants for future maintenance.
Two Implant Supported Overdenture Treatment
Among all the implant supported prosthesis , two implant supported over-denture treatment is the most cost effective treatment modality for restoring the mandibular arch , which also effectively meets the functional , social as well as economic expectation of the patients.
This video post is for both, the professionals performing implant dentistry as well as the general population.
With this video one can gather the basic understanding of the restorative treatment phases of the implant supported over-denture , which include :
- the implants ( usually placed in the first surgery / stage 1 surgery ) ,
- the healing abutments ( placed over the implants in a second surgery / stage 2 surgery )
- the attachment of the ball abutments on the implants
- incorporation of their retentive components in the dentures in this case the Gold Caps from NOBEL BIOCARE ( so the dentures can anchor onto the ball abutments in the mouth )
At the same time , for the professionals the aim of the video is to demonstrate the importance of soft tissue examination and evaluation before , during and after the stage 2 surgery has been performed and the commencement of the restorative phase with the attachment of the abutments(*** only the immediate postoperative of Stage 2 Surgery and the Restorative phase with ball abutments thereafter have been shown in this video ) .
All the implant surgeons will agree to the fact that the importance of a healthy keratinized soft tissue should not be undermined at any of the above mentioned stages , as it can impact the long term success of the implants .
Dr.Varun Malhotra
Praxisclinic video
New Microsite on Dental Cosmetics
Praxisclinic launches their new micro-website www.praxiscosmetic.com. This site is an offshoot of the main website of the centre and is pertaining to the clinical dental cosmetic cases being performed at Praxisclinic.
Dr.Varun Malhotra
Locating the MB2 Canal in Maxillary Molars .
Many studies have revealed that the second mesio-buccal canal or MB2 is a frequent finding in the Maxillary molars, with the incidence reaching to more than 60 % in the 1st Molars and more than 35 % in the 2nd Molars .
As clinicians , we notice quite a number of unsuccessful endodontic treatments in maxillary molars attributed to a missed MB2 Canal, and surprisingly these numbers are quite high.
But what leads to missing out these MB2 canals while the other 3 are mostly easily located? Well this is usually due to diffuse calcifications , anatomic variations , pulp stones asoociated with this canal , while in retreatment cases the access to the MB2 may be totally blocked out due to obturation materials and or sealers and mostly by dentinal debris in addition to the previously mentioned reasons .
Magnification and MB2
To locate the orifice of the MB2 , the clinician needs to make a serious attempt to find one during the treatment and this sometimes involves long clinical time . In addition some form of magnification either by loupes or an operating microscope when routinely employed goes a long way in ensuring the success rate of such a procedure .
As per a study the use of some form of magnification leads to a MB2 detection rate approximately three times than not using any magnification for the same .( J Endod. 2002 Apr;28(4):324-7.Effect of magnification on locating the MB2 canal in maxillary molars.Buhrley LJ, Barrows MJ, BeGole EA, Wenckus CS.Department of Endodontics, University of Illinois at Chicago, USA.)
Ultrasonic Instruments and MB2
With use of Magnification coupled with ultrasonic instrumentation especially designed for Micro-endodontic use , one can delicately remove tooth structure to aid in the location of these canals, simultaneously minimising the risk of any iatrogenic perforations.
Case Photos
Certain criteria can aid in the location of the MB2 canal as have been outlined with the photographs of one of our such cases. This case is of an endodontic retreatment that we performed on a maxillary 1st molar . Even though at initial visualization it seems that no additional canal is present, further exploration of the pulpal floor and removal of dentinal shelf along the MB1-Palatal canal with ultrasonic micro-endodontic tips, reveals the orifice of the MB2 canal .
Intial View of the access cavity reveals no MB2 orifice . Also note the calcified shelf adjacent to the MB Canal
- Removal of the dentinal shelf beginning from the orifice of the MB canal, moving towards the palatal canal orifice .This is preferably done with micro endodontic ultrasonic instruments ( Presently we use the Endosuccess Kit from Satelec/Acteon ,the tip being used here is the ET18 D tip).
Removal of dentin shelf beginning from the orifice of MB canal with ultrasonic tip ET18D Satelec/Acteon
2.Removal of this dentin shelf gradually reveals a developmental groove/isthmus emanating from the MB canal
Developmental Groove/Isthmus coursing towards the Palatal canal from the MB canal revealed after removal of overlying dentinal shelf
3.A Firm probing is required at this stage along this isthmus or groove to remove any debris or overlying thin dentin .
Probing the isthmus with a probe for removal of any debris or thin calcifications
4.At all stages use copious irrigation to remove all debris generated by ultrasonic and probing , as any blockage by this debris will impair all the efforts to detect the additional canals .
Orifice of MB2 located on the isthmus after probing and ultrasonic instrumentation with tip ET 20 satelec/acteon
5. Once located the canal orifice needs to be confirmed with the smaller standard hand file like #06 or #08 , and its presence and length should be confirmed before any cleaning and shaping procedures are initiated on this canal system .
Initial penetration of the MB2 with a hand file #06
Irrigation-after-location and confirmation of MB2 canal
Magnified view of the MB2 and MB1 prior to shaping and cleaning .Note the isthmus connecting the 2 canals .
** This video is of the same procedure being performed.
Today we know that one of the major causes for unsuccessful endodontic treatments are missed canals . Hence it is prudent to spend some time searching for them during every endodontic treatment and retreatment case .With a plethora of options available that aid us ranging from , the enhancement of visualisation of the operative field to precision reduction of the tooth material , the probability to locate these additional canal systems becomes higher .
But besides having all these aids at our disposal it requires perseverance and commitment along with the knowledge of the anatomical variations to make such endeavours successful .
Dr.Varun Malhotra . www.praxisclinic.in
Surgical Operating Microscope (SOM )
Surgical Operating Microscope
I have been practicing endodontics for quite a few years now, and many a times as a common perception , a statement would come up in professional discussions : “Endodontics is a blind procedure” . This statement would always bring up a fundamental question, “ How do you treat something efficiently , that you don’t see or visualize ?”
As we practice endodontics , most of us clinicians and endodontists develop the tactile sensation of finding our way through obstructions , ledges , calcifications . We develop the ability to feel the apices of teeth being treated , and bypass broken or fractured instruments in the canals.
But the point is, how accurately do we perform these procedures without actually visualizing the working field ? And yes, there are always risks of doing most of these procedures with just tactile sensation alone. As a matter of fact it’s easier said than done to retrieve a broken instrument especially if you can’t visually localize it( we may bypass it though ) , and retrieving silver cones cemented deep inside a canal system is a totally different ball game .
Now imagine, performing an endodontic procedure like any of the above, with a visual aid that practically makes you see the canal orifices as if you were sitting at the edge of the access cavity.
A Nonvital Maxillary 2nd premolar viewed under low magnification during RCT .
A good quality microscope makes it possible to magnify the visual field from 3.4 x to almost 21x by using a Magnification Changer and Eyepiece choices of 10x or 12.5 x (as of now I am using a Carl Zeiss OPMI pico in my practice ) and makes it a treat to see these structures in a totally different light when we are performing endo procedures.
Visualization of the same maxillary 2nd premolar at higher magnification . One can distinctly visualize the amount of pulpal debris adherent to the canals at this magnification.
- Manual magnification changers on the OPMI pico
Besides magnification, an important aspect of the SOM that enables distinct visualization of fine structure is the coaxial illumination of the working field. The illumination may be with xenon or a halogen lamp, and alongside different optional filters may be ordered for, like the orange filters that prevent premature curing of composite resins under the strong lighting of the SOM.
Another important feature of using the microscope is documentation of the procedure being performed. This may be achieved by using an integrated camera with the microscope. Another way of doing this is by attaching a beam splitter to the microscope, to which a Point& shoot, DSLR or a video camera may be attached .This facilitates shooting high resolution photographs of the surgical field or the entire videos of the procedure may be viewed live and recorded.
Beam Splitter
I personally prefer documenting through a video camera as it provides me the flexibility of recording live as well as still images.( You can choose between recording in Standard definition or high definition too .. provided you have huge gigabytes of storage space ..)
This also serves as an significant tool for Patient education and increases their understanding of what I , as a dentist try to convey to them about the specific procedure. Also it enables my team of assistants and doctors view the procedure live as it is being performed.
As a personal viewpoint, there is a learning curve to using a microscope and integrating it efficiently in your dental practice takes time, but once you cross over the learning point , the SOM becomes an indispensable tool for performing quality dentistry and predictable Endodontics.
Dr.Varun Malhotra , Praxisclinic. www.praxisclinic.in
Welcome to Praxisclinic.org
Dear Visitors , Friends and Colleagues ,
Praxisclinic.org is an effort to bring forth the different aspects of clinical dentistry by presenting , and discussing different clinical cases that we perform in our centre.
Along with different clinical cases we will make an effort to lay special focus on the use of new equipments , technology and specially the Surgical operating microscope in the practice of dentistry.
We also invite dental surgeons to display their cases by submitting them to us for posting them on this platform .
Dr.Varun Malhotra, Praxisclinic.
Dr.Varun Malhotra
Dr.Rupali Malhotra
